Failure to Provide Adequate Services to Ensure an Increased Range Of Motion for a Resident Suffering a Contracture

In a summary statement of deficiencies dated 03/05/2015, a state surveyor made a notation concerning the facility’s failure “to provide range of motion exercises for [a resident at the facility].” This deficient practice directly affected one resident out of 31 residents identified at the facility with contractures. During an interview on 03/02/2015, a licensed practical nurse (LPN) “indicated [the resident] had a contracture of the right leg [… and] was not receiving range of motion services and was not wearing a split on the right leg.” The facility’s ADON (Assistant Director of Nursing) stated that the resident “was not on a restorative program for range of motion.”

This deficient practice might be viewed as negligence or mistreatment due to a lack of proper treatment required to increase the resident’s range of motion. In addition, this practice also directly violates federal and state laws and the policies adopted by the facility.

Failure to Maintain Complete, Accurate and Organized Clinical Records That Meet Professional Standards to Ensure the Well-Being of Residents at the Facility

In a summary statement of deficiencies dated 06/26/2015, a state surveyor made a notation concerning the facility’s failure “to document assessments after [medical treatment was given to a resident at the facility].”

This is in response to an observation or review of a resident’s records that revealed “the resident required [a medical treatment] three times per week and to monitor arteriovenous fistula, located in the right arm, for bruit and thrills [bruit is continuously heard during systole and diastole and palpable thrill is normally continuous and soft or powerful, quick beats that suddenly collapses] every shift. The care plan also included to monitor, document and report to the position any signs or symptoms of infection to the abscess; redness, swelling, warmth or drainage.”

However, a review of assessments at the facility along with treatment administration records and progress notes indicate that “no documentation of assessment of the arteriovenous fistula […and] no documentation of checking the arteriovenous fistula for bruit and thrills or signs and symptoms of infection per the physician’s orders.”

This deficient practice might be considered negligence or mistreatment at the hands of caregivers and the facility because it directly violates federal and state nursing home regulations. It also violates the adopted practices and policies to operate Copley Health Center.

Failure to Provide Minimum Basic Levels of Care and Monitoring That Resulted in the Death of the Resident

In a summary statement of deficiencies dated 09/02/2015, complaint investigation was opened against the facility for its failure “to provide necessary care and services for [the resident] by monitoring a critically high blood glucose level, providing timely assessment of the resident’s responsiveness, notifying emergency services and initiating cardiopulmonary resuscitation.” This deficient practice “resulted in Immediate Jeopardy for [a resident] requiring blood glucose monitoring.”

The notification of immediate jeopardy was given to the facility’s Administrator, DON (Director of Nursing), Corporate Nurse, Regional Nurse and a Registered Nurse on duty. The notification indicated that the facility “failed to adequately address [the resident’s] critically high blood glucose level (584 mg/dL).” The licensed practical nurse on duty “administered an ordered insulin dose to the resident and placed a call to the resident’s physician to notify him of the abnormal value. The resident’s physician did not respond to the call in the resident’s blood sugar was not rechecked or monitored.

There was no documentation of the resident’s activity or status until [the following morning] when they [Registered Nurse on duty] found the resident unresponsive in the bathroom of his room, kneeling in front of the toilet, with his left arm between the handrail and wall and his head resting down on the toilet.” While other staff members enter the room after being called “emergency services were not called until between 6:40 AM and 6:42 AM [approximately 55 minutes after being found unresponsive].” EMS services arrived at the scene and “took over care of the resident when they arrived and assess that he had no obvious signs of life, including fixed pupils, rigor and pooling in his bilateral knees. He was pronounced deceased by an EMS physician through the EMS services at 6:57 AM.”

This deficient action could be considered mistreatment, negligence or gross negligence on behalf of the caregivers, nursing staff and facility because it directly violates state and federal regulations on properly monitoring residents that resulted in Immediate Jeopardy or cause death.

Failure to Provide Basic Standards of Care to Each Resident in the Facility

In a summary statement of deficiencies dated 10/09/2014, a state investigator made a notation concerning the facility’s failure “to ensure care plan was initiated for [the resident’s] dental needs, failed to ensure [another resident’s] care plan for urinary incontinence was based on the comprehensive bladder assessment and failed to ensure [a third resident’s] dehydration plan of care was revised after insertion of a feeding tube.” These deficient practices were confirmed in an interview with the facility’s Director of Nursing and that the care plans had not been updated as required by regulations.

The three different deficient practices might be considered negligence or mistreatment because they violate facility policies along with both state and federal regulations.

Failure to Ensure That All Residents Received Assistance with Personal Hygiene and Grooming Requirements

In a summary statement of deficiencies dated 07/08/2015, complaint investigation was opened against the facility for its failure “to consistently ensure residents were provided nail hygiene.” Observations made by state investigator revealed that a resident’s “exhibit long, jagged, dirty finger nails which were caked underneath the nail with dark substances.”

This deficit practice might be considered negligence and mistreatment to residents at the facility because it directly violates both federal and state regulations and the necessary policies adopted by the facility.

Kent Center1290 Fairchild Ave.Kent, OH 44240(330) 678-4912

A “For-Profit” 100-certified bed Medicaid/Medicare facility

Overall Rating – 2 out of 5 possible stars

Primary Concerns –

Failure to Follow Protocols on Pain Interventions to Treat Chronic Expressed Pain of a Resident at the Facility

In a summary statement of deficiencies dated 04/23/2015, a state investigator made a notation of the facility’s failure “to reassess, develop and implement interventions and consult the physician when current pain interventions did not effectively treat [a resident’s] chronic expressed pain and to address her psychosocial well-being.” This deficit practice directly affected a resident at the facility causing actual harm when the resident’s “routine pain medication was discontinued due to interaction with the prescribed antibiotic. There was no evidence alternative routine medications or non-medications were initiated in an attempt to address the resident’s continued pain.”

This deficit practice might be considered mistreatment or negligence to the resident because it is in direct violation of both state and federal regulations and adopted policies utilized within the facility.

In a summary statement of deficiencies dated 03/06/2015, a state surveyor made a notation in regards to the facility’s failure “to correctly assess the peripherally inserted central catheter site for [a resident] observer medication administration.” This deficit practice witnessed during an observation on 03/06/2015 at 2 PM by the state surveyors who observed a registered nurse “was preparing to administer the intravenous antibiotic Impenamine through [the resident’s] peripherally inserted central catheter (PICC) located in the resident’s left upper arm.

After cleansing the port of the PICC line using an alcohol swab, and flushing the line with 10 milliliters of normal saline, the register nurse connected the line with antibiotic to the port. However, “no attempt was made to determine if the site had any blood return and when questioned indicated “it should have been checked prior to administering the antibiotic and it was not done.”

This deficient practice might be considered substandard care, negligence or mistreatment of the resident because it directly violates policies at the facility supported by both federal and state regulations.

Longmeadow Care Center565 Bryn MawrRavenna, OH 44266(330) 297-5781

A “For-Profit” 105-certified bed Medicaid/Medicare facility

Overall Rating – 2 out of 5 possible stars

Primary Concerns –

Failure to Follow Care Management Protocols to Ensure the Highest Well-Being of Every Patient

In a summary statement of deficiencies dated 11/20/2014, a state surveyor made a notation in regards to the facility’s failure “to ensure blood sugar monitoring was complete per physician’s order.” This deficient practice directly affected one resident and “have the potential to affect 54 residents with orders for blood sugar monitoring.” The review of the physician’s orders and medical records indicated that the resident’s “most recent glycohemoglobin completed on 09/03/14 was elevated (Glycohemoglobin is a laboratory test which reflects the blood sugar level over a three-month period and is used to assist in long-term control of blood sugar).”

While the surveyor reviewing the resident’s Medication Administration Record noted that there was “one blood sugar completed on 11/17/14 at 6 AM No other blood sugars were documented. Review of the resident’s record revealed no other blood sugars had been completed since 10/20/14”, which was later confirmed by the facility’s Director of Nursing.

This deficient practice might be considered substandard levels of care at the facility, or negligence or mistreatment because it directly violates facility policy and state and federal regulations.

Failure to Implement a Planned Restorative Splint Program to Improve the Ability of a Resident to Care for Themselves

In a summary statement of deficiencies dated 09/24/2015, a state surveyor made a notation in regards to the facility’s failure “to ensure a planned restorative program was implemented for [the resident at the facility who required restorative programs].” This deficient practice directly involved one resident who was interviewed along with her daughter on 09/22/2015. The interview revealed that the resident “was on a restorative splint program. She was to wear splints for several hours per night. “

However, the state tested nurses’ aides (STNAs) knew nothing about the splints and the splints were not even in her room. A follow-up interview with [and LPN (licensed practical nurse)] revealed restorative aides were often pulled to work on the floor and when this happened restorative programs were not implemented. [The LPN] confirmed documentation indicated the upper extremity exercise program had never been completed from the date it was implemented to the time it was discontinued.”

This ongoing long term deficient practice of providing substandard care might be considered mistreatment or negligence of the resident because it does not follow facility policies and violates state and federal regulations.

Failure to Provide Residents an Environment Free of the Spread of Infections

In a summary statement of deficiencies dated 04/02/2015, a state investigator made a notation indicating the facility’s failure “to provide proper infection control during a dressing change to an ulcer on the left heel.” This deficient practice directly affected one resident. The incident was observed during a dressing change that occurred on 04/02/2015 at 1:20 PM when it was “revealed licensed practical nurse (LPN) remove the elastic wrap and dressing with gloved hands and without changing her gloves, she picked up the Dakins solution on the clean gauze, cleaned the heel ulcer, threw the gauze away, picked up [the prescribed medication] and Santyl ointment on clean gauze and put the 2 x 2’s on the heel also with the same gloves used to take the elastic wrap and soil dressing off with.”

This deficient practice of providing care when changing a residence dressing is in direct violation of the facility’s policy and procedures title Dressing Change that requires the removal of nonsterile gloves and the performance of handwashing hygiene to establish a clean field before conducting the remaining parts of the procedure. The unsterile action of changing a resident’s dressing is also in direct violation of state and federal regulations and could be considered mistreatment or negligence.

In a summary statement of deficiencies dated 02/25/2015, a state investigator made a notation in regards the facility’s failure “to implement physician’s orders … for non-pressure related skin conditions.” This deficient practice directly affected one resident at the facility. The state investigator upon reviewing nursing progress notes of a resident “revealed the [resident’s] wound treatment including placing a band-aid on the skin tear on the right hand.” However, reviewing the physician’s orders, and the Treatment Administration Record (TAR) did not show evidence of the physician’s order.”

However, observations on 0/23/15 it 9:11 AM revealed [that the resident] had a reddened, open area near the thumb of the right hand. Interview with [the resident] at the time of the observation revealed the resident hit her hand on the side of the bed causing an open area.” In an interview conducted with the facility’s Director of Nursing revealed [the resident] did not receive the physician ordered wound treatment on 02/21/15, 02/22/15 and 02/23/15.”

This deficient substandard level of care might be considered negligence or mistreatment because it directly violates state and federal regulations and does not follow the policies adopted by the facility to ensure optimal care of every resident.

In a summary statement of deficiencies dated 11/04/2014, a state investigator made a notation in regards to the facility’s failure “to provide adequate supervision to prevent the elopement of [2] cognitively impaired residents” who has a history of elopements. This deficient “lack of adequate supervision resulted in the immediate jeopardy” for these two residents.

“The immediate jeopardy began on 07/02/14 when [a recently admitted resident who has a history of eloping] eloped out of a window about five hours after admission. [The resident] was found by the police at a Pavilion in the center of town. Documentation revealed emergency medical staff noted some minor scratches and abrasions to the [resident’s] hands. The immediate jeopardy continued on 08/31/14, [involving another resident also with a history of eloping]. After an intense search of the area with support from the County Sheriff’s office, two air drones, surrounding police and fire departments, [that resident] was found by a fire fighter. He was dehydrated and transported to an area hospital.” Additionally, the facility also “failed to ensure adequate supervision was implemented to prevent falls for [another resident at the facility] who sustained multiple falls resulting in injuries.”

The deficient lack of supervision and implementation plans to prevent eloping and falls at the facility might be considered negligence or mistreatment of the residents. This is because these deficient actions or lack of actions directly violate the facilities policies and federal and state regulations.

Failure to Follow Protocol to Report and Investigate Any Act or Report of Abuse, Neglect or Mistreatment at the Facility

In a summary statement of deficiencies dated 02/11/2015, a state investigator made a notation concerning the facility’s failure “to ensure allegations of abuse, misappropriation or injury of unknown origins were thoroughly investigated.” This deficient action directly affected to residents at the facility. The incident involved a STNA (state tested nurse aide) who “had only worked at the facility for about a week and had cared for the resident one time but never went into the room by herself. [The STNA] stated herself and [another STNA] reposition the resident in bed by pulling up under her arms (between her armpit and elbow) and did not use the draw sheet. The resident held onto my elbow with her left hand. The resident told [the STNA] to be careful when touching her skin because she bruised easily. Later that evening [another STNA] came and got [the first STNA and showed her] the bruising on top of the resident’s left hand and stated it was from when [she] pulled her up in bed. [The newly employed STNA] verified she did not tell the nurse.”

This deficient practice might be considered a level of substandard care, mistreatment or neglect by the hands of the caregivers at the facility. This is because it directly violates state and federal laws and does not follow the adopted policies of the facility.

Failure to Notify the Ohio Department of Health immediately of a Self-Reported Incident of Abuse

In a summary statement of deficiencies dated 05/15/2015, a state investigator made a notation concerning the facility’s failure “to ensure one SRI [self-reported incident] was reported to the Ohio Department of Health immediately. This deficient practice involved one resident and other employees at the facility. A review of the 05/12/2015 SRI revealed that the resident informed and LPN “that the Maintenance Director had repeatedly hit her in the stomach. [The resident] informed [the LPN] the incident occurred on Sunday (05/10/15) in the afternoon. [The resident] revealed the Maintenance Director punched her and she hit him back.

An assessment was completed to the resident abdominal area, there was no redness, tenderness or bruising noted. The Maintenance Director was immediately suspended pending the investigation […. and] the allegation was submitted to the Ohio Department of Health [3 days later].” The delay in submitting a report to the Ohio Department of Health is in direct violation of the facilities policies dated 11/07/14 that indicate that the “Executive Director, Director of Nursing or designee will report immediately to the appropriate agencies and document the time and date of the report on the investigation form.”

This deficient lack of action might be considered negligence, mistreatment and abuse of the facility and employees because it does not follow facility policies and violates state and federal regulations.

In a summary statement of deficiencies dated 06/18/2015, a notation was made by a state surveyor concerning the facility’s failure “to revise a toileting program to restore or maintain bladder function for [a resident at the facility] reviewed for urinary incontinence.” This deficient practice directly affected one resident and indirectly affects the 159 residents identified to have frequent or occasional incontinence of bladder. The notation was made because of the facility’s inability to “access a tracker for [a resident]” to determine the type of incontinence/toileting program residents require in a three day tracker. The inaccurate records including the admission Minimum Data Set (MDS) assessment was accessible but the information was not complete.

This deficient standard of care and lack of documentation might be considered negligence or mistreatment of the resident because it does not follow the rules and regulations of state and federal laws and the policies adopted by the facility.

Failure to Provide Minimum Standards of Medical Care to Ensure the Highest Well-Being of the Resident

In a summary statement of deficiencies dated 08/06/2015, a state investigator made a notation concerning the facility’s failure “to assess an open area on [a resident’s] left great toe, and also failed to notify the physician and the unit manager.” This deficient practice affected one resident at the facility who is given a new order dated 08/04/15 to have the left big toe area cleansed using normal saline before applying hydrogen polymer dressing, which was then to be covered with addressing of gauze and tape. The dressing was ordered to be changed on Mondays, Wednesdays and Fridays. However, “on 08/05/15 at 1:15 PM, the podiatrist was in the facility to trim the resident’s toenails. [Minutes later,) when [the Director of Nursing] removed the gauze dressing from [the resident’s] big toe […and] confirmed there was dry bloodied drainage on the interior of the dressing. The area had a foul smell, the skin around the toe was swollen and inflamed, the podiatrist stated the resident had an ingrown toenail and he would have to excise that area. The podiatrist ordered salt water soaks and ordered a treatment. The treatment was to cleanse the left great toe with normal saline, pat dry, apply triple antibiotic ointment and cover with a non-adherent pad, secure with tape, and to change the dressing daily.”

This deficient of providing medical care to residents might be considered mistreatment or negligence on behalf of the staff at the facility. This is because it directly violates state and federal regulations and does not adhere to the adopted policies at the facility.

Stow Glen Health Care Center4285 Kent Rd.Stow, OH 44224(330) 686-2545

A “For-Profit” 100-certified bed Medicaid/Medicare facility

Overall Rating – 2 out of 5 possible stars

Primary Concerns –

Failure to Ensure That All Residents Receive the Right Medication

In a summary statement of deficiencies dated 07/23/2015, a state investigator made a notation concerning the facility’s failure “to ensure a medication administration error rate of less than 5%. There were three errors out of a possible 30 opportunities for an error rate of 10%” that affected three residents at the facility. This notation is made in response to a review of the facility’s policies and procedures relative to administering medication which revealed “medication labels should be checked three times against the Medication Administration Record.”

Any failure to properly administer the right medication to a resident at the facility places their health and well-being in jeopardy. This deficient practice of making medication administration errors might be considered negligence on behalf of the medical staff in charge of providing a safe environment to every resident in the facility. In addition, the excessive error rate directly violates state and federal regulations.

Failure to Ensure Residents Are Safe in Their Environment by Hiring Staff without Disqualifying Offenses on Their Criminal Background Check Record

In a summary statement of deficiencies dated 04/07/15, a notation is made by a state surveyor concerning the facility’s failure “to ensure their abuse policy and procedure was implemented related to the screening of new employees and failed to ensure staff had the knowledge to appropriately implement the facility’s abuse policy and procedure related to the protection of residents.” This deficient action “have the potential to affect the 69 residents residing in the facility.”

This failure to follow protocols was found after review of a newly hired LPN whose personnel file revealed it did not include evidence of license verification. Review of the facility’s criminal background check log revealed [the LPN’s] fingerprints were sent for criminal background check but there was no date indicating when or if the final report was received.” However, “after further investigation the Administrator was able to determine the final report was received [and that the LPN] had a disqualifying offense and was hired based on personal character standards.” This deficient action is in direct violation state and federal laws and does not follow the hiring practices, procedures and protocol adopted by the facility to provide care to residents in a safe environment.

Failure to Follow Hiring Practices to Ensure That All Employees Are Properly Screened Before Working at the Facility

In a summary statement of deficiencies dated 10/09/2014, a notation is made by a state surveyor concerning the facility’s failure “to implement procedures to screen potential employees for history of abuse, neglect or mistreating residents including attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries.” This deficient practice has the potential to directly affect all 81 residents at the facility. The deficit involved a lack of adequate background screening prior to the start of employment for five STNAs (state tested nurse aides) and social service workers working at the facility.

This deficient practice of hiring employees places every resident in jeopardy and could be considered neglect, or abuse if a resident suffers harm, injuries or death at the hands of a caregiver. In addition, this undesirable practice directly violates federal and state regulations and does not follow the facility’s adopted policies and procedures for hiring employees.

Placing a Loved One in a Nursing Home

Nursing facilities, assisted-living homes and rehabilitation centers are required by law to provide every elder at their facility a safe environment and quality care. Our Akron nursing home lawyers understand that many senior citizens become victims at the hands of those who are given the responsibility to ensure their safety. Many common warning signs and symptoms of abuse and neglect in nursing facilities are often overlooked by families, friends and doctors. Some of these include:

Overmedication or Improperly Medicated – A resident who has become sleepier, drowsier, or more disoriented or confused might be medically overdosed or unmonitored and suffering adverse side effects from a prescribed drug at a dosage that needs adjusting.

Skin Deterioration Caused by Incontinence – A resident who loses the ability to toilet without some kind assistance typically wears disposable breeds and can experience a breakdown of their skin caused by sitting in feces and urine.

The Inability to Maintain Dignity and Respect – Residents with poor personal hygiene can have their dignity taken away by the facility staff members when smelling of feces or urine, body odor, unwashed hair, dirty clothing or overgrown nails caused by a lack of assistance when bathing, toileting or dressing.

A Lack of Mobility – Without proper exercise or routine walking, the resident can quickly lose mobility that can dramatically decrease their quality of life and increase the potential of complicating existing medical conditions.

Unsafe Conditions – Many residents slip and fall unnecessarily due to unsafe or hazardous conditions inside the facility that is often caused by negligence or a lack of maintenance. The most hazardous areas include wet floors, broken handrails and unsanitary conditions.

The Spread of Infection – If the nursing staff does not take appropriate measures the infection suffered by one resident can easily spread to others in the facility.

Any sign of elder abuse requires immediate intervention by supervisors, administrators, family members, friends or attorneys.

Hiring a Lawyer

If you suspect your loved one has any sign or symptom of nursing home neglect, abuse or mistreatment it is essential to take immediate legal action. The nursing home abuse attorneys at Rosenfeld Injury Lawyers LLC specialize in handling cases where nursing home residents have been victimized with bedsores, bruises, unexplained weight loss, staff inattention, unnecessary chemical/physical restraint and other unacceptable behaviors of the administrator, medical director and nursing staff.

If you notice your loved one in a nursing home has any present or past warning sign it is crucial to begin an investigation immediately. We encourage you to make contact with our Akron elder abuse law firm today by calling (800) 926-7565 for your free case evaluation. As your legal advocate, we can demand answers and evaluate your claim to obtain financial compensation for the harm the nursing facility caused. All information you share with our experienced nursing home abuse case attorneys remains confidential.

For additional information on Ohio laws and information on nursing homes look here.

If you are looking for information on specific facility or an attorney, please see links below to respective locality pages.

Jonathan did a great job helping my family navigate through a lengthy lawsuit involving my grandmother's death in a nursing home. Through every step of the case, Jonathan kept my family informed of the progression of the case. Although our case eventually settled at a mediation, I really was impressed at how well prepared Jonathan was to take the case to trial. Lisa

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After I read Jonathan’s Nursing Home Blog, I decided to hire him to look into my wife’s treatment at a local nursing home. Jonathan did a great job explaining the process and the laws that apply to nursing homes. I immediately felt at ease and was glad to have him on my side. Though the lawsuit process was at times frustrating, Jonathan reassured me, particularly at my deposition. I really felt like Jonathan cared about my wife’s best interests, and I think that came across to the lawyers for the nursing home. Eric